Provider Demographics
NPI:1235279787
Name:NORTHEASTERN NEPHROLOGY ASSOCIATES, PC
Entity Type:Organization
Organization Name:NORTHEASTERN NEPHROLOGY ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANGELITO
Authorized Official - Middle Name:C
Authorized Official - Last Name:BACAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-872-8563
Mailing Address - Street 1:281 HARTFORD TPKE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-4784
Mailing Address - Country:US
Mailing Address - Phone:860-872-8563
Mailing Address - Fax:860-870-4857
Practice Address - Street 1:281 HARTFORD TPKE
Practice Address - Street 2:SUITE 210
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-4784
Practice Address - Country:US
Practice Address - Phone:860-872-8563
Practice Address - Fax:860-870-4857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT029990174400000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT=========OtherTAX ID